Affordable Care Act

“Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Paige Winfield Cunningham of The Washington Post and Margot Sanger-Katz of The New York Times discuss the continuing efforts in Congress to ‘repeal and replace’ the Affordable Care Act, upcoming open enrollment for individual insurance and Congress’s long healthcare to-do list for September.

“Plus, for ‘extra credit,’ the panelists recommend their favorite health stories of the week they think you should read, too.”

Single-payer healthcare is still a controversial idea in the U.S., but a majority of physicians are moving to support it, a new survey finds.

Fifty-six percent of doctors registered either strong support or were somewhat supportive of a single-payer health system, according to the survey by Merritt Hawkins, a physician-recruitment firm. In its 2008 survey, opinions ran the opposite way — 58 percent opposed single-payer. What’s changed?

Red tape, doctors tell Merritt Hawkins. Phillip Miller, the firm’s vice president for communications, said that in the thousands of conversations its employees have with doctors each year, physicians often say they are tired of dealing with billing and paperwork, which takes time away from patients.

“Physicians long for the relative clarity and simplicity of single-payer. In their minds, it would create less distractions, taking care of patients — not reimbursement,” Miller said.

In a single-payer system, a public entity, such as the government, would pay all the medical bills for a certain population, rather than insurance companies doing that work.

A long-term trend away from physicians owning their practices may be another reason that single-payer is winning some over. Last year was the first in which fewer than half of practicing physicians owned their practice — 47.1 percent — according to the American Medical Association’s surveys in 2012, 2014 and 2016. Many doctors are today employed by hospitals or healthcare institutions, rather than working for themselves in traditional solo or small-group private practices. Those doctors might be less invested in who pays the invoices, Miller said.

There’s also a growing sense of inevitability, Miller said, as more doctors assume that single-payer is on the horizon.

“I would say there is a sense of frustration, a sense of maybe resignation that we’re moving in that direction, let’s go there and get it over with,” he said.

Merritt Hawkins emailed its survey Aug. 3 and received responses from 1,003 doctors. The margin of sampling error is plus or minus 3.1 percentage points.

The Affordable Care Act established the principle that everyone deserves health coverage, said Shawn Martin, senior vice president for advocacy at the American Academy of Family Physicians. Inside the medical profession, the conversation has changed to how best to provide universal coverage, he said.

Dr. Steven Schroeder, who chaired a national commission in 2013 that studied how physicians are paid, said the attitude of medical students is also shifting.

Schroeder has taught medicine at the University of California-San Francisco Medical Center since 1971 and has noticed students’ increasing support for a single-payer system, an attitude they likely carry into their professional careers.

“Most of the medical students here don’t understand why the rest of the country doesn’t support it,” said Schroeder.

The Merritt Hawkins’ s findings follow two similar surveys this year.

In February, a LinkedIn survey of 500 doctors found that 48 percent supported a “Medicare for all” type of system, and 32 percent opposed the idea.

The second, released by the Chicago Medical Society in June, reported that 56 percent of doctors in that area picked single-payer as the “best care to the greatest number of people.” More than 1,000 doctors were surveyed.

Since June 2016, more than 2,500 doctors have endorsed a proposal published in the American Journal of Public Health calling for a single-payer to replace the Affordable Care Act. The plan was drafted by the Physicians for a National Health Program (PNHP), which says it represents 21,600 doctors, medical students and health professionals who support single-payer.

Clare Fauke, a communications specialist for the organization, said the group added 1,065 members in the past year and membership is now the highest since PNHP began in 1987.

Amid all the turbulence over the future of the Affordable Care Act, one facet continues unchanged: President Trump’s administration is penalizing more than half the nation’s hospitals for having too many patients return within a month.

Medicare is punishing 2,573 hospitals, just two dozen short of what it did last year under former President Obama, according to federal records released Aug. 2. Starting in October, the federal government will cut those hospitals’ payments by as much as 3 percent for a year.

Medicare docked all but 174 of those hospitals last year as well. The $564 million that the government projects to save also is roughly the same as it was last year under Obama.

High rates of readmissions have been a safety concern for decades, with one in five Medicare patients historically ending up back in the hospital within 30 days. In 2011, 3.3 million adults returned to the hospital, running up medical costs estimated at $41 billion, according to the federal Agency for Healthcare Research and Quality.

The penalties, which begin their sixth year in October, have coincided with a nationwide decrease in hospital repeat patients. Between 2007 and 2015, the frequency of readmissions for conditions targeted by Medicare dropped from 21.5 percent to 17.8 percent, with the majority of the decrease occurring shortly after the health law passed in 2010, according to a study last year in the New England Journal of Medicine conducted by Obama administration health-policy experts.

Some hospitals began giving impoverished patients free medications that they prescribe for their recovery, while others sent nurses to check up on patients seen as most likely to relapse in their homes. Readmissions dropped more quickly at hospitals potentially subject to the penalty than at other hospitals, another study found.

“The sum of the evidence really suggests that this program is helping people,” said Dr. Susannah Bernheim, the director of quality measurement at the Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation, which measures readmission rates for Medicare.

But the pace of these reductions has been leveling off in the past few years, indicating that the penalties’ ability to induce improvements may be waning.

“Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term,” the New England Journal article said.

An analysis by Bernheim’s group found no decrease in the overall rate of readmissions between 2012 and 2015, although small drops in the medical conditions targeted by the penalties continued.

“We have indeed reached the limits of what changes in how we deliver care will allow us to do,” said Nancy Foster, vice president for quality at the American Hospital Association. “We can’t prevent every readmission. It could be that there is further room for improvement, but we just don’t know what the technique is to make that happen.”

The Hospital Readmissions Reduction Program was created through a section of the ACA designed to use the purchasing power of Medicare to reward hospitals for higher quality. Those penalties, along with other ones aimed at improving hospital care, have been spared the partisan rancor over the law, and they would have continued under the GOP repeal proposals that stalled in Congress. But they have also been largely ignored.

Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health, said the fight over abolishing the Affordable Care Act has drowned out talk about how to make the health care system more effective. “We’ve spent the last six months fighting about how we’re going to pay for health insurance, which is one part of the ACA,” he said. “There’s been almost no discussion of the underlying health care delivery system changes that the ACA ushered in, and that is more important in the long run to be discussing because that’s what’s going to determine the underlying costs and outcomes of the health system.”

The readmission penalties are intended to neutralize an unintended incentive in how Medicare pays hospitals that had profited from return patients. Medicare pays hospitals a lump sum for a patient’s stay based on the nature of the admission and other factors. Since hospitals generally are not paid extra if patients remain longer, they seek to discharge patients as soon as is medically feasible. If the patient ends up back in the hospital, it becomes a financial benefit as the hospital is paid for that second stay, filling a bed that would not have generated income if the patient had remained there continuously.

Because of how the readmission-penalty program was designed, it is not surprising that the new results are so similar to last year’s. As before, Medicare determined the penalties based on readmissions of the same six types of patients: those admitted for heart attacks, heart failure, pneumonia, chronic lung disease, hip or knee replacements or coronary artery bypass graft surgery. Hospitals were judged on patients discharged between July 2013 and June 2016. Because the government looks at a three-year period, two of those years were also examined in determining last year’s penalties.

This year, the average penalty will be 0.73 percent of each payment Medicare makes for a patient between Oct. 1 and Sept. 30, 2018, according to a Kaiser Health News analysis. That too was practically the same as last year. Forty-eight hospitals received the maximum punishment of a 3 percent reduction. Medicare did not release hospital-specific estimates for how much lost money these penalties would translate to.

More than 1,500 hospitals were exempted from penalties this year as required by law. Those include hospitals treating veterans, children and psychiatric patients. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, were excluded. So were Maryland hospitals because Congress has given that state extra leeway in how it distributes Medicare money.

Of the 3,241 hospitals whose readmissions were evaluated, Medicare penalized four out of five, KHN’s analysis found. That is because the program’s methods are not very forgiving: A hospital can be penalized even if it has higher than expected readmission rates for only one of the six conditions that are targeted. Every non-excluded hospital in Delaware and West Virginia will have their reimbursements reduced. Ninety percent or more will be punished in Arizona, Connecticut, Florida, Kentucky, Massachusetts, Minnesota, New Jersey, New York and Virginia. Sixty percent or fewer will be penalized in Colorado, Kansas, Idaho, Montana, Oregon, South Dakota and Utah.

Since the readmission program’s structure is set by law, the administration cannot make major changes unilaterally, even if it wanted to.

Congress last year instructed Medicare to make one future alteration in response to complaints from safety-net hospitals and major academic medical centers.

They have objected that their patients tended to be lower income than other hospitals and were more likely to return to the hospital, sometimes because they didn’t have a primary care doctor and other times because they could not afford the right medication or diet. Those hospitals argued that this was a disadvantage for them since Medicare bases its readmission targets on industry-wide trends and that it hurt them financially, depriving them of resources they could use to help those same patients.

Bernheim noted that despite those complaints, safety-net hospitals have shown some of the greatest drops in readmission rates. In October 2018, Medicare will begin basing the penalties on how hospitals compared to their peer groups with similar numbers of poor patients. Akin Demehin, director of policy at the hospital association, said, “We expect the adjustment will provide some relief for safety-net hospitals.”

Medicare is planning to release two other rounds of recurring quality incentives for hospitals later this year. One gives out bonuses and penalties based on a mix of measures, with Medicare redistributing $1.9 billion based on how hospitals perform and improve. The other, the Hospital-Acquired Condition Reduction Program, cuts payments to roughly 750 hospitals with the highest rates of infections and other patient injuries by 1 percent.

FierceHealthcare reports that some of “the few remaining consumer operated and oriented {health} plans (CO-OPs) have turned to reorganization in order to survive. But for one, even that strategy has run into trouble.”

CO-OPs, created under the Affordable Care Act and with federal funding to get going, were to provide an additional coverage option on the individual marketplaces. “Yet they have struggled financially, and of the original 23, only a handful remain, including New Mexico Health Connections, Montana Health CO-OP, Mountain Health (of Idaho), Maine Community Health Options and Minuteman Health,” Fierce reports.

“One of the erstwhile CO-OPs, Maryland-based Evergreen Health, announced late last year that it would transition to a for-profit company owned by private equity investors in order to stay afloat.”

“That plan, which had received regulatory approval, unraveled last week after the insurer’s potential acquirers claimed new financial information surfaced that ‘raised significant concerns’ about the deal, according to the Baltimore Business Journal. Thus, the investment group—composed of Anne Arundel Health System, LifeBridge Health and JARS Health Investments—backed out.

“Following that development, the Maryland Insurance Administration announced that it had issued an order that bars Evergreen Health from selling or renewing any insurance policies.”

“While Evergreen’s bid to remake itself has failed, another East Coast CO-OP—Minuteman Health—is beginning its own transformation. The insurer, which serves customers in Massachusetts and New Hampshire, announced in late June that it plans to shed its CO-OP identity and transition into the Minuteman Insurance Company.” The organization has since been put under state control.

“Both Minuteman and Evergreen have blamed much of their financial woes on being required to pay large assessments to the Affordable Care Act’s risk-adjustment program, which is supposed to help even the playing field for individual market insurers. In two separate lawsuits against the government, they argue that the program unfairly penalizes smaller, vulnerable insurers and benefits larger carriers.”

After the Senate fell short in its effort to repeal the Affordable Care Act, the Trump administration is poised to use its regulatory powers to accomplish what lawmakers could not: shrink Medicaid.

President Trump’s top health officials could engineer lower enrollment in the state-federal health insurance program by approving applications from several GOP-controlled states eager to control fast-rising Medicaid budgets.

Indiana, Arkansas, Kentucky, Arizona and Wisconsin are seeking the administration’s permission to require adult enrollees to work, submit to drug testing and demand that some of their poorest recipients pay monthly premiums or get barred from the program.

Maine plans to apply Tuesday. Other states would likely follow if the first ones get the go-ahead.

Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said absent congressional action on the health bill “the administration may be even more proactive in engaging with states on waivers outside of those that are already planning to do so.”

The hope, he added, is that fewer individuals will be on the program as states figure out ways “to transition able-bodied enrollees into new jobs, or higher-paying jobs.” States need to shore up the program to be able to keep meeting demands for the “truly needy,” such as children and the disabled, he added.

To Medicaid’s staunchest supporters and most vocal critics alike, the waiver requests are a way to rein in the $500 billion program that has undergone unprecedented growth the past four years and now covers 75 million people.

Waivers have often been granted in the past to broaden coverage and test new ways to deliver Medicaid care, such as through private managed-care organizations.

But critics of the new requests, which could be approved within weeks, said they could hurt those who are most in need.

The National Health Law Program “is assessing the legality of work requirements and drug testing and all avenues for challenging them, including litigation,” said Jane Perkins, the group’s legal director.

The administration has already said it favors work requirements and in March invited states to suggest new ideas.

Before taking the top job at the Centers for Medicare & Medicaid Services, Seema Verma was the architect of a Kentucky waiver request submitted last year.

Not all states are expected to seek waivers, because Medicaid enjoys wide political support in many states, particularly in the Northeast and West.

Medicaid, the nation’s largest health insurance program, has seen enrollment soar by 17 million since 2014, when Obamacare gave states more federal funding to expand coverage for adults. It’s typically states’ second-largest expense after education.

This year, Senate and House bills tried to cap federal funding to states for the first time. Since the program began in 1965, federal Medicaid funding to states has been open-ended.

Health experts say allowing the waiver requests goes beyond the executive branch’s authority to change the program without approval from Congress.

“The point of these waivers is not for states to remake the program whole-cloth on a large-scale basis,” said Sara Rosenbaum, a health-policy expert at George Washington University who chairs a Medicaid group that advises Congress.

Rosenbaum noted that states received waivers for different purposes under the Obama administration.

In Iowa, state officials won the authority to limit non-emergency transportation. Indiana received approval to charge premiums and lock out enrollees with incomes above the federal poverty level if they fell behind on paying premiums.

“Now there is concern these more extreme measures would hurt enrollees’ access to care,” Rosenbaum said.

Three states seeking waivers today are home to three key GOP players in the Senate health debate: Majority Leader Mitch McConnell (Kentucky), Sen. John McCain (Arizona) and Vice President Mike Pence (Indiana).

If states add premiums, as well as work and drug testing requirements, the result would be fewer people enrolling and staying in Medicaid, said David Machledt, senior policy analyst for the National Health Law Program.

“How does that serve the purpose of the Medicaid program and what are the limits of CMS waiver authority?” he asked.

“Driven by a strong performance in its health insurance marketplace business, Centene reported better-than-expected second-quarter earnings on Tuesday—the same day Senate Republicans were poised to vote to advance legislation to repeal the Affordable Care Act.

“The insurer, which primarily specializes in Medicaid managed care, said its its profits rose to $254 million ($1.44 earnings per share) in the quarter, up from $171 million in the second quarter of 2016. Its adjusted EPS of $1.59 beat analysts’ consensus estimate of $1.30 per share, and it raised its full-year guidance by 18 cents to a range of $4.70 to $5.06 per share.

“Centene said its “strong 2017 marketplace performance” exceeded its expectations in the second quarter by $0.12 diluted earnings per share, and added that its second-quarter earnings of 17 cents per share net benefit related to risk adjustment under the ACA.

“The insurer previously said it would expand its ACA exchange presence in 2018, even as policy uncertainty has driven other insurers to exit.”

Seven years of Republican vows to “repeal and replace” the Affordable Care Act came to a crashing halt Tuesday, when it became clear that the Senate could not muster the necessary votes for any of three separate proposals that have been under consideration.

The failure, at least for now, breaks one of the key promises Republicans have made to their voters since 2010, when the ACA first became law.

“This has been a very challenging experience for all of us,” Senate Majority Leader Mitch McConnell (R.-Ky.) told reporters Tuesday afternoon. “It’s pretty clear that there are not 50 Republicans at the moment to vote for a replacement for Obamacare.”

Monday night’s declaration of opposition by conservative Senators Mike Lee (R-Utah) and Jerry Moran (R-Kan.) effectively scotched even the chance to start debate on the version of a bill unveiled last week.

McConnell added that the Senate would vote early next week on a plan, originally approved in 2015 and vetoed by President Obama, that would repeal parts of the health law. That approach would delay the effective date for two years to give lawmakers time to come up with a replacement.

“To just say ‘repeal and trust us, we’re going to fix it in a couple of years,’ that’s not going to provide comfort to the anxiety a lot of Alaskan families are feeling right now,” Murkowski told reporters.

In retrospect, Republicans’ inability to overhaul the health law should not come as much of a surprise. Here are some of the reasons:

1. It’s hard to take things away from people.

Once launched, federal programs that provide people with benefits they find important and valuable are very difficult to rescind. In the case of healthcare, people’s lives can be at stake. In the current debate, patients who feared what would happen to their health coverage made their concerns known — loudly — to lawmakers.

2. Republicans have long been divided on health care.

Republicans’ dirty little secret the past seven years is that the only thing they fundamentally agreed on when it comes to healthcare was the slogan “repeal and replace.” There’s a reason they failed to have a plan ready when Donald Trump was elected president — all efforts to reach a consensus had thus far failed.

“I did not come to Washington to hurt people,” said Capito. “I have serious concerns about how we continue to provide affordable care to those who have benefited from West Virginia’s decision to expand Medicaid.”

But the more conservative members, notably Sen. Rand Paul (R.-Ky.), have other priorities. “All of us promised we would repeal Obamacare,” Paul told reporters Tuesday. “If you’re not willing to vote the way you voted in 2015 then you need to go back home and you need to explain to Republicans why you’re no longer for repealing Obamacare.”

3. Presidential leadership on hard issues is important.

President Trump has been all over the place in what he said he wanted from a health bill. It was his original insistence that “repeal and replace” happen simultaneously that moved Congress away from its 2015 strategy of repealing first and replacing later. He hosted a celebration in the White House Rose Garden when the House passed its bill, then subsequently called the measure “mean” during a strategy meeting with senators.

When it became clear Monday night that the Senate effort was foundering, Trump tweeted: “Republicans should just REPEAL failing ObamaCare now & work on a new Healthcare Plan that will start from a clean slate.” But within hours he instead suggested, “As I have always said, let ObamaCare fail and then come together and do a great healthcare plan.”

The president “gave them an impossible assignment with his promises (more, better, cheaper for all) and neither policy nor bully pulpit help at crunch time,” said Len Nichols, a professor of health policy at George Mason University. “And now he’ll blame them for failing.”

Added Thomas Miller, of the conservative American Enterprise Institute: “We now have a randomized clinical trial that proves one cannot lead and govern via Twitter.”

4. Healthcare is complicated. Really.

Healthcare has not traditionally been a major voting issue for Republicans, and thus it has been a low priority — compared with issues like taxes and trade — for the officials they elect.

Adding to the complexity is that the Republicans’ bench is nowhere near as deep as the Democrats’ when it comes to health -policy expertise. Democrats have toiled on these issues for years. Even before the Affordable Care Act, many had served in Congress for decades and learned from the mistakes that were made on efforts like the failed health bill under President Clinton.

5. Some parts of the ACA really are popular, even among Republicans.

The requirement for most people to have insurance or else pay a fine — the individual mandate — has consistently been unpopular among voters of all political stripes. But many other major provisions of the health law, such as guaranteeing coverage for people with preexisting conditions, remain broadly popular.

In fact, in recent months, the Affordable Care Act has been growing in popularity. Most polls show it more than twice as popular as GOP efforts to overhaul it.

“Republicans have to admit that some of the things in the ACA, we actually liked,” said Murkowski.

That left a huge gap between Republicans who wanted to maintain the popular benefits and those who wanted to repeal the law entirely. A gap that, so far, Republicans have been unable to bridge.

The very rich but nonprofit Cleveland Clinic continues to gobble up property in the low-income neighborhood around it as the health system expands abroad to sell its services to rich people there.

As an article in Politico reports:

“The Clinic is a global success story, but its host community remains mired in poverty.

There’s an uneasy relationship between the Clinic — the second-biggest employer in Ohio and one of the greatest hospitals in the world — and the community around it. Yes, the hospital is the pride of Cleveland, and its leaders readily tout reports that the Clinic delivers billions of dollars in value to the state….”

“But it’s also a tax-exempt organization that, like many hospitals, fought to preserve its not-for-profit status in the years leading up to the Affordable Care Act. As a result, it doesn’t have to pay tens of millions of dollars in taxes, but it is supposed to fulfill a loosely defined commitment to reinvest in its community.

“That community is poor, unhealthy and — in the words of one national neighborhood-ranking website — “barely livable.”

“It’s the paradox at the heart of the Cleveland Clinic, as it lures wealthy patients and expands into cities like London and Abu Dhabi. Its stated mission is to save lives. But it can’t save the neighborhood that continues to crumble around it.”

Beyond the sound and fury over Republican efforts to kill the Affordable Care Act, some providers are renewing calls for healthcare-delivery reform, says a piece in Health Affairs by Robert Pearl, M.D., and Norman Chenven, M.D. They have led, respectively, two of the nation’s highest-performing healthcare systems: Kaiser Permanente and the Austin Regional Clinic. Dr. Pearl is chairman and Dr. Chenven vice chairman of the Council of Accountable Physician Practices.

Among their observations:

“Policymakers who are focused predominantly on how to improve the health care system by providing health insurance coverage will fail unless they simultaneously focus on transforming and modifying the delivery system; otherwise, the cost of providing that care will erode any program they create, whether coverage is provided through private insurance, Medicare, Medicaid, or another method. For this reason, we encourage the new Administration and members of Congress to consult and rely on the nation’s physician leaders, in addition to health insurance executives, to help chart the course for American health care in the future.

“While there are many different ‘levers’ to pull for delivery system improvement, three are absolutely fundamental to bringing about positive change and enhancing the doctor-patient relationship: As a nation we will need to move rapidly from fee-for-service to value-based reimbursement, and from paper and stand-alone computer systems to comprehensive, integrated, and mobile electronic health records. At the same time, we will need to track quality and patient satisfaction in ways that improve clinical outcomes without overly burdening physicians. We believe that all three of these objectives can be accomplished, and that they need to be central to the approaches and legislation currently being contemplated by policymakers.”

They conclude:

“The impending crisis in health care in this country will not be averted, regardless of what happens to the Affordable Care Act, unless as a nation we move from fragmentation to integration, from volume- to value-based payment, and from paper records and stand-alone computers to interoperable and comprehensive electronic ones. If these delivery system issues are ignored in the rancorous debate about health care coverage, then no matter the outcome, the system will fail.”

ATLANTA — Each day as Ginger Peebles watches daughter Brenlee grow, she sees the importance of having a hospital close by that delivers babies.

Brenlee’s birth was touch-and-go after Peebles realized something was wrong. “I couldn’t feel the baby move, and my blood pressure was sky-high,” said Peebles, a nurse.

Dr. Roslyn Banks-Jackson, then an OB-GYN specialist at Emanuel Medical Center in Swainsboro, Ga., diagnosed preeclampsia, a potentially lethal complication of pregnancy, and induced labor to save Peebles and the baby. Brenlee was born on Oct. 28, 2014, completely healthy.

Had Peebles given birth the following year, she might not have been so fortunate, she said. Emanuel shuttered its labor-and-delivery unit the next spring, becoming one of a handful of such units in the state to close from 2010 to 2015, most because of budget problems. Another is expected to close this month, said Daniel Thompson, executive director of the Georgia OBGyn Society.

Republican bills to replace the federal health law would worsen rural areas’ financial straits through reductions in Medicaid funding. Patient advocates predict that would lead to fewer enrollees, more shutdowns of rural facilities, reduced payments to doctors and fewer programs for people with health needs or disabilities. In the aggregate, such changes threaten the health of thousands of state residents, especially those in rural areas.

“I’ve seen changes, and I’ve seen cuts, but I’ve never seen changes like what’s being proposed in this bill,” said Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities. “This is the first time it’s been this scary.”

Possible Strains on a Lean Budget

One of the key aims of the House and Senate bills is reversing the Affordable Care Act’s expansion of Medicaid. But the legislation also would institute changes to the federal-state health program for low-income residents that could devastate states such as Georgia that didn’t expand Medicaid. Georgia already ranks 45th in the nation in per capita Medicaid spending, according to the Georgia Budget and Policy Institute.

The bills would switch Medicaid from an entitlement — in which the federal government agrees to pay its share of costs for anyone who qualifies for the program — to a system in which the federal government by 2020 would limit its payments and reimburse states based on a per capita formula.

The nonpartisan Congressional Budget Office concluded in a report released June 29 that the Senate plan would slash 35 percent of expected federal Medicaid funding by 2036.

“Cuts now would cripple rural Georgia,” said Dr. Ben Spitalnick, president of the Georgia chapter of the American Academy of Pediatrics.

He said that is because most primary-care visits, which include OB-GYN, pediatric and adult care, in the state’s sparsely populated areas rely heavily on Medicaid reimbursements.

The federal cutbacks would have to be offset by the state. But that means taking money from other programs or raising taxes. As a result, state officials facing those shortfalls would likely scale back an already lean Medicaid coverage.

“If you cut back, [people] still go to the hospital, they’ll still need care. No matter what you do, the buck stops somewhere,” said Renee Unterman, a Republican state senator who chairs the health and human services committee. In the end, she added, the cost for that uncompensated care gets passed to taxpayers and consumers through higher health costs and insurance premiums.

Georgia’s rural hospitals have proved vulnerable. Five closed in the past five years and another two merged. Plus, several have closed their emergency rooms.

That translates to a loss of doctors in affected counties. Of Georgia’s 159 counties, 79 do not have an OB-GYN specialist, and 65 do not have a pediatrician, according to 2015 figures from the Georgia AAP and the Georgia OBGyn Society.

Close to 1.7 million Georgians, or nearly 1 in 5 state residents, live in these areas, according to figures from the Rural Health Information Hub.

Improving Pay for Doctors

For 15 years, Georgia Medicaid reimbursed primary care doctors at only 60 percent of the amount that the federal Medicare program reimbursed similar services, said Ward.

But in 2015, the Legislature implemented three rounds of pay increases to primary care doctors, including pediatricians and OB-GYNs, to bring them in line with the Medicare reimbursement.

Many of these doctors are now concerned those rates would be the first to be lowered. “That’s our big fear,” said Rick Ward, executive director of the Georgia chapter of the AAP. “We just clawed our way back and to deal with it again would just be unbelievable.”

Key among those concerns are prenatal care in rural areas. With a maternal-mortality rate that is among the worst in the country, OB-GYNs are worried that the cuts would eliminate fragile solutions to doctor shortages that the state has implemented.

For example, pregnant, low-income women in 17 counties around Augusta can arrange for a ride in a van, paid for by Medicaid, for their prenatal visits at the medical school at Augusta University. The service has been vital in keeping these women healthy and insuring successful births. Advocates fear it is the type of program that could face problems if Medicaid funding becomes tight.

People With Disabilities Fearful

Advocates for residents with disabilities worry that home health care would be likely to suffer from the cuts.

That’s because while states are required under Medicaid to pay for nursing home stays, care for people living at home has been optional.

About 38,000 people in the state get the services, also called community-based benefits. Qualifying takes years, and benefits are not guaranteed, even for people who are eligible. Almost 10,000 Georgians are on the waiting list, according to Jacobson, because there is not enough money in the Medicaid budget to cover everyone.

One of those who is getting coverage is Joshua Williams, 22, who has severe cerebral palsy and needs constant care at home and school.

“I’m terrified” that funding cuts could end the program, said his mother, Mitzi Proffitt, 53. “I’d have to quit my job” to take care of him. Williams’s stepfather, Jack Proffitt, 65, has advanced cancer and cannot provide much assistance.

Joshua Williams

Williams, who is on the dean’s list at East Georgia State College in Swainsboro and loves NASCAR, also admits to being “very scared.” He said if his coverage is discontinued, he would have to drop out of college, ruining his hopes of becoming a sports broadcaster. He is eager to get a part-time job until he graduates.

“I want to work. I don’t want handouts,” he said.

A supporter of President Trump’s, Williams said he is counting on the president to keep disability benefits in place and to ensure that health care is affordable for all.

“He thinks that if Trump knew his story, he’d get on this and fix things,” said Mitzi Proffitt.

“I like him because he’s a businessman, but he said he has heart,” Williams added.